PYLEPHLEBITIS.

This occurs in two forms, adhesive and suppurative, which have been already referred to, the one as a cause of ascites (p. 589), the other in connection with multiple abscesses of the liver.

ADHESIVE PYLEPHLEBITIS.

This is more generally a thrombosis of the portal vein, in which the clot adheres to the wall of the vein, and becomes ultimately organized in the same way as thrombi in other situations. Its causes are those changes which bring about retardation of the blood current in the portal vein or its distribution, such as cirrhosis, syphilitic disease, the pressure of tumors on the trunk of the vein, or its implication in perihepatitis, or chronic peritonitis near the fissure of the liver.

Symptoms.-The obstruction to the portal vein necessarily leads to symptoms closely resembling, or identical with, those of cirrhosis, viz., engorgement of the portal vein radicles, showing itself in ascites, with enlarged spleen, diarrhoea, and hemorrhage from gastric and intestinal vessels. The collateral circulation becomes developed in the same way as in cirrhosis, and the superficial abdominal veins are commonly enlarged, relieving thus, for a time, the portal vessels.

The Diagnosis from cirrhosis of the liver is generally difficult. It must depend on the absence of alcoholic history, or the known presence of conditions which might cause portal thrombosis; but most such conditions are themselves possible causes of direct portal obstruction and ascites.

Its Treatment is similar to that of cirrhosis.

SUPPURATIVE PYLEPHLEBITIS.

This is generally secondary to inflammation in some part of the area from which the portal vein arises, such as ulcer of the stomach, perityphlitis, dysenteric ulcers of the intestine, suppuration of the mesenteric glands, or abscess of the spleen. Nearer the liver, gall stones may set up inflammation of the portal vein branches, or the same may happen from suppuration about a hydatid cyst. In the new-born the portal vein may be the subject of septic phlebitis through the umbilical vein.

The mischief commonly begins either in the branches or in the tributaries of the portal vein, rather than in the trunk itself, to which, however, the suppurative process may ultimately extend. The wall of the vein inflames and suppurates, a thrombus forms in the neighborhood, breaks down into pus, and in its conveyance to other parts of the vessel sets up fresh centres of thrombosis, phlebitis, and suppuration. Finally, in many cases, multiple abscesses of the liver are formed.

The Symptoms are nearly the same as those of multiple abscesses.

There are epigastric and hypochondriac pain, fever of hectic type, rigors, sweating, vomiting, and prostration. The portal vein may be sufficiently obstructed to cause some ascites, and the spleen is enlarged, partly on this account, partly as a result of septic fever. Jaundice is often, but not always, present; and, if abscesses are numerous, there may be enlargement of the liver.

The disease runs an acute course, is generally fatal, and can only be treated on the principle of merely relieving symptoms.

DISEASES OF THE PANCREAS.

The pancreas is subject to pathological processes similar to those that occur in other organs; but it is rarely that its lesions are recognizable by well-marked clinical features. For either the symptoms are obscure, or they are referred to adjacent organs, such as the liver, stomach, and duodenum.

Pancreatitis.-Acute inflammation of the pancreas sometimes occurs in infective diseases, such as typhoid fever, pyæmia and septicemia; or it may arise by extension from neighboring parts. In typhoid fever it is commonly of the parenchymatous form, the connective tissue being infiltrated with leucocytes, and the gland cells in a state of cloudy swelling. But in other cases there is suppurative inflammation, the organ being larger, swollen, and either infiltrated with pus, or containing separate abscesses. In the typhoid group of cases, no symptoms are generally observed, but in some other cases the following have been observed: Severe continuous pain in the epigastrium, either dull, or shooting to the back or shoulder; tension and tenderness of the epigastrium; vomiting, thirst, constipation; and finally, collapse and death.

Chronic Pancreatitis affects the intestinal tissue, producing consider. able fibrous growth, with consequent atrophy of the glandular structures, analogous to the changes in cirrhosis of the liver. The head of the organ is usually most affected. It commonly arises from the spread of adjacent inflammations, such as those of the peritoneum, of the bile duct, or of a gastric ulcer. It also results from the presence of concretions in the pancreatic duct, or of retained pancreatic secretion; from the irritation of cancer, from the venous congestion of heart disease; and possibly from syphilis, and the use of alcohol. Chronic inflammation is one of the changes that are sometimes found in association with diabetes. The symptoms are rarely prominent. Occasionally, on account of diminution or loss of the pancreatic secretion, the fatty contents of the food are imperfectly digested, and fatty stools are passed, in which an oily liquid is actually present, or lumps of white or yellow tallow-like fat. This may occur in any severe

chronic lesion of the pancreas, but it is not constant, since the bile assists in the solution of fatty matters. It has already been shown that fatty stools may occur when the biliary secretion is retained. Dr. Walker, of Peterborough, has brought forward cases to prove that the absence of the pancreatic secretion causes the stools to be clay-colored, although the bile is normally excreted; and this he explains by supposing that the coloring matter of the fæces is only formed as a result of the coöperation of the pancreatic secretion with that of the liver.

Atrophy, Fatty Degeneration, Fatty Infiltration, and Lardaceous Degeneration also affect the pancreas.

Hemorrhage sometimes takes place as a result of the congestion of heart disease, and blood cysts may form in the substance of the gland. A few instances are on record where hemorrhage seemed to be the sole cause of death.

In

Pancreatic Concretions.-These consist of calcium carbonate and calcium phosphate. They may be like grains of sand, or as large as hazelnuts, and are usually round or oval, occasionally irregular or branched. color they are white, or grayish-white; sometimes brown, or nearly black. They sometimes block the duct or its branches, and lead to dilatation of the ducts, retention cysts, acute inflammation with suppuration or chronic induration, or even to inflammation in the parts around. They rarely produce symptoms, except through their secondary effects for instance, by the inflammation which they excite, or by the cysts, which in rare instances have been large enough to be felt.

Tumors. Of these carcinoma is the most important, whether primary or secondary. Sarcoma, tubercle, and gumma only occasionally occur. Primary cancer is generally of the scirrhous variety, forming hard nodules in the head of the organ, to which part it is not unfrequently confined. An irregular nodular hard tumor is thus formed, which may be of sufficient size to be felt under favorable circumstances through the abdominal parietes. As the cancer nodules increase in size the pancreatic duct is liable to be obstructed, with the formation of cysts as a result. And the common bile duct is not unfrequently blocked either by pressure or by the spread of a chronic inflammation. Jaundice in either case results. In other instances the cancer may involve the stomach, duodenum, peritoneum, vertebræ, or other structures. The symptoms in cancer of the pancreas are deep-seated pain, of aching, gnawing, lancinating, or burning character, which Dr. F. T. Roberts points out is often distinctly paroxysmal in its occurrence, and is affected by food, coughing, deep breathing, movement or posture. Nausea and vomiting may be present; and sometimes fatty stools. Examination. may reveal a tumor of the characters described in the situation of the head of the pancreas. In the later stages emaciation, anæmia, and prostration become prominent features of the case.

Treatment is mainly directed to the relief of symptoms. Removal of some tumors by operation may be possible.

DISEASES OF THE PERITONEUM.

PERITONITIS.

The peritoneum lining the surface of the abdomen, and covering nearly all the viscera contained within it, is liable to inflammation from a number of causes originating in these organs. This inflammation may be acute or chronic, and general or circumscribed.

ACUTE PERITONITIS.

Etiology. The most frequent cause is extension from the abdominal viscera or adjacent parts, such as ulceration of the stomach, typhoid and tubercular ulcers of the ileum, dysenteric ulcers of the colon, inflammation of the appendix cæci, abscess of the liver, and suppuration of the gall bladder, infarction and abscess of the spleen, the numerous inflammatory lesions which are apt to involve the female pelvic organs, metritis, ovaritis, suppuration of the Fallopian tubes, pelvic cellulitis, and peri-uterine hæmatocele.

In many of these cases the peritonitis is set up, not so much by extension of inflammation, as by the discharge of irritating products-food, fæces, or pus-into the abdominal cavity, as in the case of the perforation of gastric and intestinal ulcers, in cæcal disease, and in rupture of abscesses. Peritonitis is the natural termination of most cases of intestinal obstruction, either from local inflammation, as in acute strangulation and hernia, or from rupture of over-distended gut, as in the more chronic strictures. Perinephritic and psoas abscesses may rupture into the peritoneum, and empyema occasionally sets up inflammation below the diaphragm, though it is much less common than pleurisy and empyema as a result of a peritoneal abscess. Wounds of the peritoneum, whether from injury or surgical procedure, are liable to be followed by peritonitis.

As to more general causes, it is not quite clear how far they operate. Cold has naturally been charged with being a cause in many instances, but its power in this direction is doubted by some. If peritonitis forms part of a general septicæmia or pyæmia, puerperal or otherwise, it probably arises directly from local lesions. But Bright's disease, both acute and chronic, is certainly an occasional cause of peritonitis, which is then generally fatal.

Morbid Anatomy.-The changes which take place in the peritoneum are not unlike those which occur in the pleura when it is inflamed. There is at first redness from increased vascularity, and if the cavity of the abdomen

is examined in this early stage, the redness on the intestine is commonly seen to be most marked along two parallel lines, which are determined by the diminished atmospheric pressure in the space between any two coils and the abdominal wall (hence, called suction lines by the late Dr. Moxon). This injection is soon followed by the effusion of lymph or pus. There is at first a mere stickiness of the peritoneal surface, but the lymph soon becomes more abundant, forming yellowish flakes, coating the surface of the bowel, or collecting in larger masses in the angles and sulci between the coils. With this lymph, which consists of fibrin and leucocytes, there may be a varying amount of turbid serum. The rapidity with which this forms is very remarkable, as may be seen in some traumatic cases, where a quantity of yellow lymph may be found in less than eighteen hours. In some less severe or less extensive cases, the lymph may develop into fibrous tissue, by the growth. of some leucocytes into fibres, and of others into blood-vessels, and the dif ferent viscera are united together, or the peritoneal cavity is obliterated by the adhesions which are thus formed.

In other cases, the quantity of leucocytes increases, or is more numerous, from the first, and the inflammatory products are entirely purulent; this is often quickly fatal, but occasionally a large peritoneal abscess may slowly form, and offer chances of recovery.

Acute peritonitis is sometimes, from the first, circumscribed, and results in a localized abscess, which may point externally or open into one of the hollow viscera. Such abscesses occur in the pelvis, between the diaphragm and the liver, or between the diaphragm and the spleen. In these last two situations they may rupture into the chest, and set up pleurisy or pneumonia. The contents of a peritoneal abscess not unfrequently decompose, either from direct communication with the interior of the intestine, or from mere contact with it; in the former case, a fecal fistula will result if the abscess be opened externally.

Symptoms.-Acute general peritonitis begins with pain, which is mostly very severe, and, if at first localized to one spot, soon becomes diffused over the whole abdomen. The pain is constant, but aggravated by every kind of movement, by coughing, straining, or vomiting. It is not relieved by pressure; on the contrary, there is marked tenderness over the whole of the abdomen. Vomiting, as a rule, soon sets in, and occurs repeatedly, either spontaneously, or after attempts to take food. At first the gastric contents are brought up, subsequently bile, and later still, in some prolonged cases, the vomited matters may have an almost feculent character. The temperature commonly rises, reaching 102° or 103°, more rarely 104° or 105°, and the pulse is quick, 100 to 120; sometimes, also, rigors occur at the commencement; but there is always a considerable degree of collapse.

In some cases of perforation of gastric or intestinal ulcer, the patient sinks from collapse in twenty-four hours. In others, the patient is soon obliged